THE ANNEX BLOG
In Health there was Something to be Done – Aneurin Bevan and the Origins of the NHS
In Health, there was something to build on, but not much. Lloyd George had introduced the National Insurance Act in 1911. It meant that workers could obtain medical treatment paid for by their insurance premiums. But wives and depend- ants were excluded, the treatment available was restricted, and there was an income limit for participation in the scheme.
Most people still could not afford the cost of treatment if they were seriously ill. Every day, people died when treatment which could save them was available, but beyond their means. Hospitals lived largely on charitable donations. Some areas were desperately short of doctors and hospitals.
The wartime coalition government had produced a health scheme, but nothing had been done about implementing it, and in any case the scheme itself was inadequate. Even so, it had already aroused the wrath of the British Medical Association (BMA), and the Conservative Health Minister had started making concessions which would render it unworkable.By January 1946 Aneurin Bevan had outlined what became the National Health Service, a scheme which imposed on the Health Minister a duty to provide a comprehensive health service, free of charge, paid for not by insurance but by taxation. To do this, the hospitals, which were run by local authorities or voluntary organisations, were to be nationalised. Bevan insisted that if the nation did not own the hospitals, the minister could not provide a National Health Service – he could only exhort others to do so. He could not spread the best consult- ants around the country unless he could offer them interesting jobs and a secure financial future. And he could not guarantee the right of a sick person to a hospital bed. In any case, local authorities could not run hospitals effectively, and private benefactors should not. ‘The benefactor tends also to become a petty tyrant, not only willing his cash but sending his instructions along with it,’ said Bevan. ‘It is repugnant to a civilised community for hospitals to have to rely on private charity … I have always felt a shudder of repulsion when I see nurses and sisters who ought to be at their work … going about the streets collecting money for the hospitals.’
Bevan was certain that his National Health Service could not work if he left hospitals with their present owners and bought in their services. Already between 80 and 90 per cent of voluntary sector hospitals’ money came from public funds, so why should they not be accountable? It was a brave decision, adding local authorities and the voluntary sector to the list of his enemies.
For general practitioners he proposed a small basic salary, set in 1946 at £300 a year, plus fees based on the number of patients on a doctor’s list. He proposed to abolish the GP’s right to buy and sell practices. All of this was intended to make it easier for young doctors starting out in the profession, without capital, to obtain a practice, and to help the minister to ensure that medical services were spread reasonably evenly throughout the country and not concentrated in wealthy areas. The Bill’s first hurdle was the Cabinet. Herbert Morrison had spent years in local government and did not like seeing hospitals taken away from it. Others feared the political consequences of offending local authorities, or were concerned at the cost.
Bevan started to realise the crucial, if often silent, force of the Prime Minister, as even Michael Foot grudgingly recognises:
wish to take away my admiration for Attlee, but he could not forgive the man for his cruelty towards Harold Laski. Attlee’s support was needed, because the BMA was outraged at the proposals for GPs. It said they ‘could lead sooner rather than later to doctors becoming a branch of the Civil Service’. Its leaders were amazingly unrestrained in their abuse of Bevan. Former BMA Secretary, Dr Alfred Cox, wrote that the proposals ‘look to me uncommonly like the first step, and a big one, towards National Socialism as practised in Germany. The medical service there was early put under the dictatorship of a “medical fuhrer”. This Bill will establish the Minister of Health in that capacity.’
‘We shall become West Indian slaves,’ said another influent BMA figure, Dr Roland Cockshut. ‘They had complete security subject only to two disadvantages. They could not own property and they could not move from their plantations … The Bill can be written in two lines: I hereby take power to do what I like about the medical service of the country, signed Aneurin Bevan, führer.’ Today, New Right historians make the same point, marginally less ignorantly and offensively. Correlli Barnett calls Bevan’s plan ‘a plan of military organisation produced by a general staff for a great offensive commencing with the role of the supreme commander: “General responsibility for the service will rest with the Minister of Health.”’ Governments since Margaret Thatcher’s time have tried to dismantle that one aspect of the Bevan scheme, with some success, and have always been suspected of wishing to destroy the NHS. To Bevan, that principle was the key to making a health service, free at the point of use, workable and influential.
‘Large numbers of doctors’, records the BMA’s official history ‘seemed to belong to a section of society which regarded the advent of a Socialist Government as a national disaster almost as catastrophic as a defeat by Hitler.’ If doctors refused to work in the NHS it was doomed. The Chairman of the BMA Council, Dr Guy Dain, told a special BMA assembly that it could say to the minister ‘You want the doctors. We have the doctors.’ The assembly rejected by huge majorities every item in Bevan’s plan. The Conservatives opposed the Bill tooth and nail. They saw it, as David Eccles MP put it, as part of the government’s ‘concerted attack upon the middle class’. Mr Eccles added: ‘If the Minister is determined to fight, we on these benches will not leave the doctors to fight alone.’ ‘The doctors’ stand,’ according to a Daily Graphic columnist, ‘is the first effective revolt of the professional classes against Socialist tyranny … There is nothing that Bevan or any other Socialist can do about it in the shape of Hitlerian coercion … The state medical service is part of the Socialist plot to convert Great Britain into a National Socialist economy.’
But on 6 November 1946 Bevan’s Bill received the royal assent. It was to come into operation in July 1948. There were some bad-tempered meetings between Bevan and BMA leaders which came to nothing. The BMA declared that the Act ‘is so grossly at variance with the essential principles of our profession that it should be rejected absolutely by all practitioners’.20 It told doctors not to work in the NHS. Bevan’s and the government’s nerve held. Bevan made minor concessions to enable the BMA to climb down gracefully. The scheme was massively expensive, for a country which – as American politicians never stopped reminding the government – was on its uppers and had to take its begging bowl across the Atlantic in order to feed its people. But the NHS was so popular that fairly soon both the BMA and the Conservative Party were claiming that they had been in favour of it, in principle at least. They were not. It was carried in the teeth of their opposition, and would never have come into existence at all without an exceptional minister, backed to the hilt by a Prime Minister who understood exactly what was being created, and who had dreamed of it just as much as his Health Minister had done.
There were compromises. The Act called for the creation of health centres, comprising GPs, chemists and equipment; this foundered on BMA opposition, and the traditional GP surgery remained the norm. The leader of English Catholics, the Arch- bishop of Westminster, Cardinal Bernard Griffin, negotiated the opting out of Catholic hospitals from the new NHS.
But the National Health Service came into being, bang on schedule, on 5 July 1948, instantly becoming the world’s third biggest employer after the Red Army in the Soviet Union and the Indian National Railways. The same day saw the introduction of Jim Griffiths’s social security measures and free school meals. By that day, three-quarters of the population had signed up with doctors under the NHS scheme. By September the figure was 93 per cent. Nine out of ten GPs participated from the start. Attlee was the last person ever to show his feelings or talk about them, but it was probably one of the proudest days of his life. In the broadcast he made the previous day, his voice sounds, if not ecstatic – it would not have had the tempo to express ecstasy – deeply contented: